Page 108 - Cover Letter & Evaluation for David Steenburgen

Blue Cross Blue Shield of Arizona Medicare Supplement Premium Rate Information
(Tobacco Use)

Rates are effective January 1, 2018

BlueValue Rate
You may be eligible to receive a lower premium BlueValue rate. In certain situations, you may be
automatically eligible to receive the BlueValue rate, regardless of your medical history.
These rates apply to age 73 and above.

BlueValue rate Monthly Quarterly Semi-Annual Annually
Senior Security Plan A $186.18 $558.54 $1,117.08 $2,234.16
Senior Security Plan C $249.96 $749.88 $1,499.76 $2,999.52
Senior Security Plan D $225.23 $675.69 $1,351.38 $2,702.76
Senior Security Plan F $260.38 $781.14 $1,562.28 $3,124.56
Senior Security Plan G $227.83 $683.49 $1,366.98 $2,733.96
Senior Security Plan N $179.66 $538.98 $1,077.96 $2,155.92
Senior Preferred Plan C $229.13 $687.39 $1,374.78 $2,749.56
Senior Preferred Plan D $200.50 $601.50 $1,203.00 $2,406.00
Senior Preferred Plan G $210.91 $632.73 $1,265.46 $2,530.92
Senior Preferred Plan N $156.23 $468.69 $937.38 $1,874.76

Standard Rate
If you don’t qualify for the BlueValue rate, you will receive a standard rate.
These rates apply to age 73 and above

Standard rate Monthly Quarterly Semi-Annual Annually
Senior Security Plan A $300.67 $902.01 $1,804.02 $3,608.04
Senior Security Plan C $403.69 $1,211.07 $2,422.14 $4,844.28
Senior Security Plan D $363.74 $1,091.22 $2,182.44 $4,364.88
Senior Security Plan F $420.52 $1,261.56 $2,523.12 $5,046.24
Senior Security Plan G $367.95 $1,103.85 $2,207.70 $4,415.40
Senior Security Plan N $290.16 $870.48 $1,740.96 $3,481.92
Senior Preferred Plan C $370.04 $1,110.12 $2,220.24 $4,440.48
Senior Preferred Plan D $323.81 $971.43 $1,942.86 $3,885.72
Senior Preferred Plan G $340.63 $1,021.89 $2,043.78 $4,087.56
Senior Preferred Plan N $252.32 $756.96 $1,513.92 $3,027.84

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